Diabetic Nephropathy

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Diagnosis

Early screening for microalbuminuria is essential for all patients with diabetes. Aggressive intervention can delay and possibly stop progression through the stages of diabetic nephropathy (DN). Patients often seek medical attention only after having progressed to stage 3 or 4. Those who have reached stage 3 should be referred to a nephrologist (kidney specialist). The nephrologist monitors ongoing management and conducts further diagnostic studies to exclude nondiabetic causes for protein in the urine (proteinuria).

Treatment

Treatment for diabetic nephropathy attempts to manage and slow the progression of the disease.

Aggressive blood pressure control is by far the most important factor in protecting kidney function, regardless of the stage of DN. The goal of treatment is:

• 120–130 mm Hg systolic blood pressure and
• 70–80 mm Hg diastolic blood pressure.

Angiotensin-converting enzyme (ACE) inhibitors protect the kidneys more effectively than other high blood pressure medications. A new class of blood pressure medications known as angiotensin-receptor blockers (ARBs) may offer comparable protection. Patients who cannot tolerate ACE inhibitors may use an ARB (e.g., losartan, valsartan). Maximum doses of an ACE along with an ARB may provide additional renal protection in people who can tolerate the medications. Both ACE inhibitors and ARBs can cause hyperkalemia (abnormally high level of potassium in the blood) in patients with chronic renal failure.

Strict blood sugar control is important in the protection of kidney function. Intensive blood sugar regulation requires frequent monitoring and commitment.

Dietary protein restriction is minimally protective. A high-protein diet (e.g., the Atkins diet) can further damage the kidneys in people with diabetic nephropathy and/or chronic renal failure (CRF). Protein restriction must be cautiously implemented because of the risk for malnutrition. In general, dietary protein intake should be limited to 0.6 to 0.8 grams per kilogram (0.02–0.028 oz/lb) of body weight each day.

Renal Replacement Therapy
Once patients with DN progress to stage 5 (end-stage renal disease, ESRD), renal replacement therapy (RRT) is implemented. The RRT options for DN patients include the following:

• Hemodialysis, removal of the blood's waste products through filtration outside of the body
• Peritoneal dialysis, filtration through the membrane lining the abdominal cavity; fluid is instilled into the peritoneal space, and then drained
• Kidney transplantation

Patients with DM 1 are possible candidates for combined kidney and pancreas transplantation. A healthy insulin-producing pancreas eliminates the diabetes and the potential for developing diabetic nephropathy.

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